This invention relates to the use of angiostatic steroids, which are known to have reduced or no systemic side effects typical of glucocorticoids, mineralocorticoids and sex steroids, for the promotion of angiogenesis and thus wound healing when used in combination with hyaluronan (for example hyaluronan and pharmaceutically acceptable salts thereof). This invention in one particular application may be used in creams, lotions, sprays, suppositories, and gels and the like for application in wound healing for delivery of for example an effective amount of tetrahydro steroids in combination with an effective amount of hyaluronic acid to the wound site, for example to treat incisions, burns, skin lesions, and ulcers. Equally appropriate applications would be administration of the invention intradermally, transdermally, intermuscularly, intramuscularly and intravenously when appropriate.
It is well documented that tetrahydro steroids such as tetrahydrocortisol (TH-F), tetrahydrocortisone (TH-E) and tetrahydrocortexolone (TH-S) are known not to possess the detrimental systemic side effects normally associated with glucocorticoids, mineralocorticoids and sex steroids since they do not bind to appropriate receptors such as do known glucocorticoids, mineralocorticoids and sex steroids. Typically, the continued use of glucocorticoids, mineralocorticoids and sex steroids for chronic ailments may result in a number of well known documented side effects such as bone wasting, fluid retention and infections. Therefore, these glucocorticoid steroids, mineralocorticoids and sex steroids are normally not recommended for a chronic program of treatment for patients. Thus for wound healing for chronic type wounds such as dermatitis, skin ulcers, hemorrhoids, and the like although they would benefit from the use of these aforementioned steroids, the expected systemic side effects would materialize.
The tetrahydra steroids are themselves angiostatic steroids. Other steroids are also angiostatic or anti-angiogenic steroids. They are known not to possess detrimental systemic side effects normally associated with glucocorticoids, mineralocorticoids and sex steroids. These angiostatic steroids have therefore very much reduced detrimental side effects (and in some instances are known not to possess these side effects). These angiostatic steroids are also normally associated with the inhibition of new blood vessel formation. For a discussion of the various research and use of angiostatic steroids, the reader is referred to the following listing of patents, patent applications and technical articles which are representative only and are not in any way implied to be an exhaustive listing. Throughout this disclosure, xe2x80x9cangiostatic steroidsxe2x80x9d or the like are to be assumed to mean those steroids not possessing significant angiogenetic properties.
1. Opal Ka, C. J. et al., Synthesis (1995): 766-8.
2. Cockerill, G. W. et al., International Review of Cytology (1995) 159: 113-60.
3. Diaz-Flores, L. et al.,Histology and Histopathology (October 1994) 9(4): 807-43.
4. Sipos, E. P. et al, Annals of the New York Academy of Sciences (Sep. 6, 1994); 732: 263-72.
5. Thorpe, P. E. et al., Cancer Research (Jul. 1, 1993) 53(13): 3000-7.
6. Folkman, J. and Ingber, D., Seminars in Cancer Biology (April 1992) 3(2): 89-96.
7. Ribatti, D. et al., Haematologica (July-August 1991) 76(4): 311-20.
8. Tobelem, G., Blood Coagulation and Fibrinolysis (December 1990) 1(6): 703-5.
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10. Folkman, J. et al., Science (Mar. 17, 1989) 243(4897): 1490-3.
11. Cariou, R. et al., Cell Biology International Reports (December 1988) 12(12): 1037-47.
12. Folkman, J. and Ingber, D. E., Annals of Surgery (September 1987) 206(3): 374-83.
13. Ingber, D. E. et al, Endocrinology (October 1986) 119(4): 1768-75.
14. Folkman, J., Cancer Research (February 1986) 46(2): 467-73.
15. Crum, R. et al., Science (Dec. 20, 1985) 230(4732): 1375-8.
16. Folkman, J., Pediatrics (November 1984) 74(5): 850-6.
17. Blei, F. et al., Journal of Cellular Physiology (June 1993) 155(3): 568-78.
18. Folkman, J. and Shing Y., Advances in Experimental Medicine and Biology (1992) 313: 355-64.
19. Yamamoto, T., Terada, N., Nishizawa, Y. and Petrow, V., Angiostatic Activities of Medroxyprogesterone Acetate and its Analogues (1994): 56, 393-399.
20. Colville-Nash, P., Alam, C., Appleton, I., Brown, J., Seed, M. and Willoughby, D., The Pharmacological Modulation of Angiogenesis in Chronic Granulomatous Inflammation (1995) JPET 274: 1463-1472. Since wound healing depends on angiogenesis, (the reader is directed to article 3 above at page 811 for a discussion of angiogenesis) it would be desirable to induce angiogenesis utilizing safe compounds and which compounds do not have systemic side effects typical of glucocorticoids, mineralocorticoids and sex steroids, or at least substantially reduced side effects. However, the angiostatic steroids have not previously been recognized to stimulate new blood vessel growth. See for example, article 4 and page 265 therein. Specific reference is made to article 19 above to Nishizawa which verifies that angiostatic steroids do not bind glucocorticoid, mineralocorticoid and sex steroid receptors.
Applicants have in their PCT Application WO94/23725 published on Oct. 27, 1994 by Professor Willoughby et al., utilized an NSAID in combination with a form of hyaluronic acid for controlling, inhibiting, and/or regressing angiogenesis for the treatment of tumours and other diseases and conditions.
PCT Application WO94/17840 to Fidia published Aug. 18, 1994 discusses a spongy material consisting of total or partial ester derivatives of hyaluronic acid utilized for the administration of hyaluronic acid solutions to enhance the recovery of patients suffering from decubitus ulcers, wounds and burns. This document purports to describe the capability of hyaluronic acid to induce a rapid and complete tissue repair process. It is discussed further that anti-inflammatory agents may be contained in the solutions of hyaluronic acid. Specifically, the reference purports to teach a combination of hyaluronic acid in solution with, for example, corticosteroids which include glucocorticoids and mineralocorticoids. These steroids are known to have undesirable systemic side effects.
It is therefore an object of this invention to provide a novel treatment for promoting the formation of blood vessel growth and proliferation (angiogenesis) for wound healing.
It would also be advantageous to be able to utilize substantially reduced levels of medicines for wound healing in relation to the levels normally required when the treatment involves the use of corticosteroids. Typically when corticosteroids are used for a topical treatment, formulations 0.1 to 1% incorporating corticosteroids are used. It would also be advantageous if corticosteroids are used to reduce the amount used. Furthermore, it is an object of this invention to utilize other compounds heretofore not known for promotion of angiogenesis to stimulate angiogenesis.
Further and other objects of the invention will become apparent to those skilled in the art from the following summary of the invention and the more detailed description of embodiments thereof.
According to one aspect of this invention, we have provided compositions including known steroids such as angiostatic steroids which have limited or no angiogenic effect in combination with a form of hyaluronic acid which in combination results in accelerated scarless wound healing and the stimulation of new blood vessel formation (angiogenesis).
According to another aspect of the invention, angiogenesis is promoted in wound healing treatment by, for example topical application, by utilizing significantly lower dosages of agents such as angiostatic anti-inflammatory agents such as known angiostatic steroids having significantly reduced or no systemic side effects, (when compared to glucocorticoids, mineralocorticoids and sex steroids), in combination with a form of hyaluronic acid to foster and induce angiogenesis when utilized in combination with the form of hyaluronic acid in wound healing and for the stimulation of new blood vessels in the acceleration of scarless wound healing.
According to another aspect of the invention, the compositions and treatment include steroids known not to possess detrimental systemic side effects typical of glucocorticoid, mineralocorticoid and sex steroids in combination with a form of hyaluronic acid (such as hyaluronan and pharmaceutically acceptable salts thereof) for topical application for wound healing and which combination induces angiogenesis and accelerates scarless wound healing.
Therefore, according to another aspect of the invention there is provided a pharmaceutical composition utilized for increasing neovascularization and angiogenesis during wound healing in a mammal, for example a human, beyond the level of neovascularization and angiogenesis which would occur at the wound site without any treatment, said composition comprising an effective amount of any angiostatic steroid combined with an effective amount of a form of hyaluronan such as hyaluronic acid and pharmaceutically acceptable salts thereof. Preferably, said composition includes a suitable diluent such as purified water or the like. The composition may be applied or administered nasally, vaginally, intraaurally, ocularily, rectally, orally, locally or topically at preferred levels of 0.1-3mg of said steroid per kg of body weight of the patient preferably within the order of about 2.5% hyaluronic acid by weight in the formulation. In various embodiments, 0.1-20% hyaluronic acid by weight of the formulation may be utilized and preferably 0.3-10% may be utilized. Suitable compositions may also be formulated for application of the compositions of the invention transdermally, intermuscularly, intramuscularly and intravenously when appropriate.
According to yet another aspect of the invention there is provided a method of treatment for increasing neovascularization and angiogenesis during wound healing in a mammal, for example a human, beyond the level of neovascularization and angiogenesis which would occur at the wound site without any treatment, said method comprising application of a composition including an effective amount of any angiostatic steroid combined with an effective amount of a form of hyaluronic acid (such as hyaluronan and pharmaceutically acceptable slats thereof) at the wound site. Preferably said composition includes a suitable diluent such as purified water or the like. The composition may be applied or administered nasally, vaginally, intraaurally, ocularly, rectally, orally, locally or topically at preferred levels of 0.1-3mg of the steroid per kilogram of body weight of the patient in a composition comprising in the order of about preferably 2.5% hyaluronic acid by weight. Alternatively, formulations containing 0.1-20% hyaluronic acid by weight may be utilized and preferably 0.3-10% may be utilized together with an angiostatic steroid which is in the order of 0.1-1 mg of the steroid per kilogram of body weight. Suitable compositions can be formulated for administration transdermally, intermuscularly, intramuscularly and intravenously when appropriate.
According to yet another aspect of the invention there is provided the use of a pharmaceutical composition for increasing neovascularization and angiogenesis during wound healing in a mammal beyond the level of neovascularization and angiogenesis which would occur at the wound sight without any treatment, said use of said composition comprising application of the composition containing an effective amount of an angiostatic steroid combined with an effective amount of a form of hyaluronan such as hyaluronic acid and a pharmaceutically acceptable salt thereof at the wound site. Preferably said composition also includes a suitable diluent such as purified water or the like. The composition may be applied or administered nasally, vaginally, intraaurally, ocularly, rectally, orally, locally or topically at preferred levels of 0.1-3 mg of said steroid per kg of body weight of the patient with for example 2.5% hyaluronic acid by weight of the composition. Alternatively 0.1-20% hyaluronic acid may be utilized by weight in the formulation, and more preferably 0.3-10% by weight of the composition may be a form of hyaluronic acid. Equally appropriate would be the application of the invention transdermally, intermuscularly, intramuscularly and intravenously when appropriate.
According to yet another aspect of the invention, there is provided a composition for inducing angiogenesis in the healing of a condition, such as a wound, for example for topical application, said composition comprising a form of hyaluronic acid in a suitable form and effective amount in combination with an effective amount of a suitable steroid, such as angiostatic steroids, for example tetrahydro-steroids, that are known not to possess detrimental systemic side effects or to possess significantly reduced detrimental side effects such as bone mass loss, fluid retention, infections and the like as is normally associated with glucocorticoids, mineralocorticoids, and sex steroids, said suitable steroid, such as an angiostatic steroid, (for example tetrahydro-steroids known not to stimulate new blood vessel formation when utilized individually) wherein the combination of hyaluronic acid and said suitable steroid (known to possess reduced detrimental side effects, or not to possess detrimental systemic side effects, normally associated with glucocorticoids, mineralocorticoids and sex steroids and which are normally angiostatic and inhibit new blood vessel formation), stimulates new blood vessel formation and angiogenesis to accelerate scarless healing of a condition such as a wound. Preferably, the steroids such as tetrahydrocortisol (THF), tetrahydrocortisone (THE) and tetrahydrocortexolone (THS) known not to possess detrimental systemic side effects and known to be angiostatic are the agents combined with the form of hyaluronic acid. The reader is referred to the previous prior art listing for a partial listing of typical angiostatic steroids. For example, a combination of the form of hyaluronic acid in combination with tetrahydro-steroid derivatives would be beneficial for acceleration of wound healing by the stimulation of angiogenesis.
According to another aspect of the invention, there is provided a process for the stimulation and/or induction of angiogenesis, for example, stimulation of blood vessel growth in a condition such as a wound in a mammal (for example a human), the process comprising the step of administering an effective dosage amount of a pharmaceutical composition for the stimulation and/or induction of angiogenesis to a site on/in a mammal in need of stimulation and/or induction of angiogenesis such as at a wound site, and repeating the administration for such time as required, each effective dosage amount of the composition comprising an effective non-toxic dosage amount of a steroid known to have angiostatic properties when utilized alone or in combination with known therapies, examples of which angiostatic steroids include tetrahydro-steroids, for example tetrahydrocortisone, tetrahydrocortisol or tetrahydrocortexolone or the like (for example, in solution in the composition), and an effective non-toxic dosage amount of a form of hyaluronic acid and/or a pharmaceutically acceptable salt thereof (for example, sodium hyaluronate) preferably sodium hyaluronate. Preferably, the composition may be administered topically in the form of a cream, lotion and/or gel for the treatment of burns, ulcers, incisions or the like, nasally, vaginally, intraurally, ocularly, or orally for the treatment of wounds therein or as a suppository for hemorrhoids. Administration may also comprise application transdermally, intermuscularly, intramuscularly and intravenously when appropriate.
According to another aspect of the invention, the use of a combination of a form of hyaluronic acid (for example, hyaluronic acid and a pharmaceutically acceptable salt thereof) for example, sodium hyaluronate, and a suitable steroid known not to have systemic side effects, such as angiostatic steroids, for example tetrahydro-steroids such as tetrahydrocortisol, tetrahydrocortisone or tetrahydrocortexolone and the like (among others also known not to have the systemic side effects of glucocorticoids, mineralocorticoids and sex steroids or the like,) which are also known to be normally angiostatic when administered in known compositions or solutions is provided for angiogenesis. Surprisingly and unexpectedly, this combination of the form of hyaluronic acid with the specified agent stimulates and induces angiogenesis and hence healing of a condition such as a wound. The composition may be applied or administered nasally, vaginally, intraaurally, ocularly, rectally, orally, locally or topically at preferred levels of 0.1-3 mg of said steroid per kilogram of the patient in combination with 0.1-20% by weight of the form of hyaluronic acid in the composition, preferably 0.3-10% by weight of the form of hyaluronic acid may be used in the formulation. Equally appropriate would be the application of the compositions transdermally, intermuscularly, intramuscularly and intravenously when appropriate.
Thus, an effective non-toxic dosage amount of a composition comprising an effective non-toxic dosage amount of sodium hyaluronate and a therapeutically effective non-toxic dosage amount of a known angiostatic steroid, such as tetrahydro-steroids for example tetrahydrocortisol, tetrahydrocortisone or tetrahydrocortexolone or the like is provided and may be used to stimulate and induce angiogenesis. The amount of angiostatic steroid (for example, tetrahydrocortisol, tetrahydrocortisone or tetrahydrocortexolone or the like) administered in one example may be about 0.1-3 mg/kg of body weight of the patient for application topically in a composition which comprises preferably 2.5% hyaluronic acid or salt thereof by weight for wounds in the order of 4 sq. cm. Alternatively, the composition may comprise about 0.1-20% hyaluronic acid, preferably 0.3-10% by weight of the composition may be utilized.
According to another aspect of the invention, a pharmaceutical composition (suitable for, topical application [on the skin], rectally, vaginally, intraaurally, ocularly, locally, nasally, orally, on the mucosa, etc.) is provided (for example a multigram pharmaceutical composition for use topically) effective for the stimulation and induction of angiogenesis, the pharmaceutical composition containing a plurality of dosage amounts for stimulating and inducing angiogenesis, each of said dosage amounts comprising a therapeutically effective non-toxic (to the patient) dosage amount of a steroid known to be angiostatic (for example tetrahydro-steroids) as described above and in the literature and an effective non-toxic dosage amount of the form of hyaluronic acid such as hyaluronan and/or pharmaceutically acceptable salts thereof effective to stimulate and induce angiogenesis. Equally appropriate would be the application of the composition transdermally, intermuscularly and intramuscularly when appropriate.
The pharmaceutical composition may comprise suitable excipients depending upon the route of administration for example excipients to make a gel, lotion, spray, ointment, suppository, or cream (topical administration).
According to yet another aspect of the invention, a dosage amount of a pharmaceutical composition is provided for stimulating and inducing angiogenesis at a wound site, the composition comprising:
(1) a known angiostatic steroid agent known not to have systemic side effects typical of glucocorticoids, mineralocorticoids and sex steroids, for example tetrahydro-steroids; and
(2) a form of hyaluronic acid and/or pharmaceutically acceptable salts thereof (for example sodium hyaluronate) characterized in that said composition:
(a) is in a dosage form (e.g. in a cream, lotion, gel, ointment, spray, or solution, etc.) which is suitable for administration at the wound site; and
(b) is in such an amount and in such form that component (1) is in an effective dosage amount together with component (2) to stimulate and induce angiogenesis (for example in scarless wound healing). Preferably, the pharmaceutical composition may further comprise a plurality of dosage amounts.
According to still another aspect of the invention there is provided the use of
(1) a known angiostatic steroid agent known not to have systemic side effects typical of glucocorticoids, mineralocorticoids and sex steroids, for example tetrahydro-steroids; and
(2) hyaluronic acid and/or pharmaceutically acceptable salts thereof (for example sodium hyaluronate) in the manufacture of a pharmaceutical composition for use to stimulate and induce angiogenesis in mammals (for example in humans) at a wound site, wherein dosage amounts may be taken from the composition and each dosage amount taken comprises:
a therapeutically effective non-toxic dosage amount of each of components (1) and (2) to stimulate and induce angiogenesis at said wound site.
The composition containing the form of hyaluronic acid and known angiostatic steroid provides significantly greater stimulation of angiogenesis than a composition comprising a form of hyaluronic acid (for example sodium hyaluronate) only. Thus, according to another aspect of the invention Applicants have provided similar methods of treatment, pharmaceutical compositions, dosage amounts and uses comprising forms of hyaluronic acid (for example sodium hyaluronate having a molecular weight less than about 750,000 daltons) with the angiostatic steroids known not to have systemic side effects typical of glucocorticoids, mineralocorticoids and sex steroids.
The amount of the form of hyaluronic acid (for example sodium hyaluronate) per dosage amount may vary. A concentration of 0.1-20% hyaluronic acid may be utilized in the composition by weight and preferably 0.3%-10% may be utilized. Preferably the form of hyaluronic acid (for example sodium hyaluronate) administered, has a molecular weight less than about 750,00 daltons (for example about 150,00 to about 225,000 daltons). While higher molecular weights of the hyaluronic acid and forms thereof may be used in the compositions to stimulate angiogenesis, where the molecular weight of the hyaluronic acid chosen for use is very large, the form of hyaluronic acid is autoclaved, to break down the form of hyaluronic acid to fragments of lesser molecular weight and if feasible diluted to permit administration and ensure no coagulation (whatever the route of administration). Where the molecular weight of the form of hyaluronic acid being employed is at the upper range, the concentration of the form of the hyaluronic acid in the composition may be adjusted, for example be reduced (for example to less than about 1%) dependent on the molecular weight.
Many forms of hyaluronan may be suitable although those preferred are those discussed hereinafter (identified Molecular Weights were determined using the Protein Standard):
One form of hyaluronic acid and/or pharmaceutically acceptable salts thereof (for example sodium salt) suitable for use with our invention is an amount having the following specifications/characteristics:
Another such amount may comprise:
Another such amount is available from Hyal Pharmaceuticals Limited and comes in a 15 ml vial of Sodium hyaluronate 20 mg/ml (300 mg/vial-Lot 2F3). The sodium hyaluronate amount is a 2% solution with a mean average molecular weight of about 225,000. The amount also contains water q.s. which is triple distilled and sterile in accordance with the U.S.P. for injection formulations. The vials of hyaluronic acid and/or salts thereof may be carried in a Type 1 borosilicate glass vial closed by a butyl stopper which does not react with the contents of the vial.
The amount of hyaluronic acid and/or salts thereof (for example sodium salt) may also comprise the following characteristics:
a purified, substantially pyrogen-free amount of hyaluronic acid obtained from a natural source having at least one characteristic selected from the group (and preferably all characteristics) consisting of the following:
i) a molecular weight within the range of 150,000-225,000;
ii) less than about 1.25% sulphated mucopoly-saccharides on a total weight basis;
iii) less than about 0.6% protein on a total weight basis;
iv) less than about 150 ppm iron on a total weight basis;
v) less than about 15 ppm lead on a total weight basis;
vi) less than 0.0025% glucosamine;
vii) less than 0.025% glucuronic acid;
viii) less than 0.025% N-acetylglucosamine;
ix) less than 0.0025% amino acids;
x) a UV extinction coefficient at 257 nm of less than about 0.275;
xi) a UV extinction coefficient at 280 nm of less than about 0.25; and
xii) a pH within the range of 7.3-7.9. Preferably, the hyaluronic acid is mixed with sterile water and the amount of hyaluronic acid has a mean average molecular weight within the range of 150,000-225,000 daltons (protein standard). More preferably, the amount of hyaluronic acid comprises at least one characteristic selected from the group (and preferably all characteristics) consisting of the following characteristics:
i) less than about 1% sulphated mucopolysaccharides on a total weight basis;
ii) less than about 0.4% protein on a total weight basis;
iii) less than about 100 ppm iron on a total weight basis;
iv) less than about 10 ppm lead on a total weight basis;
v) less than 0.00166% glucosamine;
vi) less than 0.0166% glucuronic acid;
vii) less than 0.0166% N-acetylglucosamine;
viii) less than 0.00166% amino acids;
x) a UV extinction coefficient at 257 nm of less than about 0.23;
xi) a UV extinction coefficient at 280 nm of less than 0.19; and
xii) a pH within the range of 7.5-7.7
Applicants may also use sodium hyaluronate produced and supplied by LifeCore(trademark) Biomedical, Inc., having the following specifications:
Another amount of sodium hyaluronate proposed to be used is sold under the name Hyaluronan HA-M5070 by Skymart Enterprises, Inc. having the following specifications:
Other forms of hyaluronic acid and/or its salts may be chosen from other suppliers and those described in prior art documents provided they are suitable.
The following references teach hyaluronic acid, sources thereof, and processes for the manufacture and recovery thereof which may be suitable.
As there is no toxicity of the form of hyaluronic acid, the form of hyaluronic acid may be administered in doses in excess of 12 mg/kg of body weight, for example, in excess of 1000 mg/70 kg person and even up to amounts of 3000 mg/70 kg person without adverse toxic effects. Lower amounts may include 10-50 mg of hyaluronan. Example amounts of Hyaluronan used may be 3-10mg of HA/kg of body weight of the patient wherein the molecular weight (protein standard) is less than 750,000 daltons.
Suitable forms of hyaluronan may have molecular weights of forms of hyaluronan between about 150,000 daltons and about 750,000 daltons (protein standard) in sterile water prepared having a viscosity for intravenous administration.
One specific form of pharmaceutical grade is a 1% sterile sodium hyaluronate solution (50 ml vials) provided by Hyal Pharmaceutical Corporation which has the following characteristics:
This pharmaceutical grade 1% sterile solution of hyaluronan may be made from granules/powder having the following characteristics:
A topical grade of hyaluronan may, in certain circumstances be suitable and may be made from the following granules/powder which have the following characteristics:
This topical grade may then be sterilized.
Other forms of hyaluronic acid and/or its salts may be chosen from other suppliers, for example those described in prior art documents disclosing forms of hyaluronic acid having lower molecular weights between about 150,000 daltons and 750,000 daltons being prepared as for example, 1-2% solutions in sterile water for intravenous administration.
The following references teach hyaluronic acid, sources thereof and processes of the manufacture and recovery thereof.
Canadian Letters Patent 1,205,031 (which refers to U.S. Pat. No. 4,141,973 as prior art) refers to hyaluronic acid fractions having average molecular weights of from 50,000 to 100,000; 250,000 to 350,000; and 500,000 to 730,000 and discusses processes of their manufacture
Where high molecular weight hyaluronic acid (or salts or other forms thereof) is used, it must, prior to use, be diluted to permit administration and ensure no intramuscular coagulation. Recently, it has been found that large molecular weight hyaluronic acid having a molecular weight exceeding about 1,000,000 daltons self-aggregates and thus, does not interact very well with HA receptors. Thus, the larger molecular weight hyaluronic acid should be avoided.
The invention will now be illustrated by reference to the following Figures and description of embodiments.